• Human PEMF New Client Intake Form

    Complete this intake once before your first appointment, including your health history and today’s concerns.

  • Client Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • Format: (000) 000-0000.

  • Health History

  • Overall Health*
  • Current Medical Conditions or Diagnoses*
  • Surgeries or Hospitalizations Within the Past Year*
  • Currently Taking Any Medications*
  • Implanted Medical Devices*
  • Metal Implants, Joint Replacements, Plates, Screws, or Surgical Hardware*
  • Currently Pregnant or Think You May Be Pregnant*
  • Ever Diagnosed with Cancer*
  • Current Unexplained Swelling, Active Infection, Fever, Blood Clot, Uncontrolled Bleeding Disorder, or Other Serious Medical Condition*

  • Current Concerns

  • What Brings You In Today?*
  • Where Are You Experiencing Symptoms?*
  • When Did Your Symptoms Begin?*
     - -
  •

  • Consent

  • Human PEMF Consent & Liability Waiver

    PEMF therapy is intended to complement—not replace—care provided by your physician or other licensed healthcare professionals.

    I voluntarily request and consent to receive Pulsed Electromagnetic Field (PEMF) therapy provided by Anna Gezon Equine Massage Therapy LLC.

    I understand that PEMF therapy is a complementary wellness modality intended to support relaxation, circulation, recovery, comfort, and overall well-being. It is not intended to diagnose, treat, cure, or prevent any disease and is not a substitute for medical evaluation, diagnosis, or treatment by a licensed healthcare provider.

    I understand that Anna Gezon is not a physician, physical therapist, chiropractor, or other licensed medical provider. No medical advice, diagnosis, or treatment is being provided.

    I certify that the information I have provided regarding my health history is complete and accurate to the best of my knowledge. I agree to inform Anna Gezon of any changes to my medical history, medications, pregnancy status, implanted medical devices, or other health conditions before each appointment.

    I understand that PEMF therapy may not be appropriate for every individual. I acknowledge that I have disclosed any implanted electronic medical devices (including pacemakers, implanted defibrillators, insulin pumps, spinal cord stimulators, cochlear implants, or other electronic implants), pregnancy, active cancer, blood clots, active infections, uncontrolled medical conditions, or other relevant health concerns.

    I understand that Anna Gezon may modify, postpone, or decline treatment if it is determined that PEMF therapy is not appropriate or if medical clearance is recommended.

    I understand that individual responses to PEMF therapy vary and that no specific results or outcomes can be guaranteed.

    I understand that I may stop treatment at any time and agree to immediately notify Anna Gezon if I experience discomfort or wish to discontinue the session.

    I voluntarily assume all risks associated with receiving PEMF therapy and release and hold harmless Anna Gezon Equine Massage Therapy LLC, its owner, employees, and representatives from any claims, injuries, damages, or liabilities arising from participation in these services, except in cases of gross negligence or willful misconduct.

    By signing below, I acknowledge that I have read, understood, and voluntarily agree to this Consent & Liability Waiver.

  • Agreements*
  • Date*
     - -

  • Optional Media Consent

  • May Anna Gezon Equine Massage Therapy LLC photograph or video your session for educational or promotional purposes?*

  • If Yes: Personal information will remain private and only your first name and image will be shared

  • If Yes: your personal information will remain private, and only your first name and image may be shared.
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